Komotar Ricardo J, Hahn David K, Kim Grace H, Khandji Joyce, Mocco J, Mayer Stephan A, Connolly E Sander
Department of Neurological Surgery, Columbia University, New York, New York 10032, USA.
Neurosurgery. 2008 Jan;62(1):123-32; discussion 132-4. doi: 10.1227/01.NEU.0000311069.48862.C8.
Chronic hydrocephalus requiring shunt placement and cerebral vasospasm are common complications after aneurysmal subarachnoid hemorrhage. Recent publications have investigated the possibility that microsurgical fenestration of the lamina terminalis during aneurysm surgery may reduce the incidence of shunt-dependent hydrocephalus and cerebral vasospasm. We reviewed a single-surgeon series to compare postsurgical outcomes of patients who underwent fenestration of the lamina terminalis against those who did not.
This study is a retrospective review of the medical records of 369 consecutive patients with aneurysmal subarachnoid hemorrhage admitted to Columbia University Medical Center between January 2000 and July 2006. All patients underwent craniotomy and clipping of at least one ruptured cerebral aneurysm by a single neurosurgeon (ESC). The incidences of shunt-dependent hydrocephalus, conversion from acute hydrocephalus on admission to chronic hydrocephalus, and clinical cerebral vasospasm were compared in patients who underwent fenestration of the lamina terminalis with those who did not. The patient cohort was thus divided into three subgroups: 1) patients whose operative records clearly indicated that they underwent fenestration of the lamina terminalis, 2) patients whose operative records clearly indicated that they did not undergo fenestration of the lamina terminalis, and 3) patients whose operative records did not indicate one way or another whether they received fenestration of the lamina terminalis. We performed two separate analyses by comparing the postsurgical outcomes in those patients who were fenestrated versus those who were definitively not fenestrated and comparing the postsurgical outcomes in those patients who were fenestrated versus those who were not plus those whose records did not document fenestration. To further control for any cohort differences, we performed a comparison between patients who were fenestrated and those who were not after matching 1:1 for presenting radiographic and clinical characteristics predictive of hydrocephalus and vasospasm. Outcomes were compared using logistic regression and multivariable analysis.
In the first model, fenestrated patients had a shunt rate, conversion rate, and rate of clinical vasospasm of 25, 50, and 23%, respectively, versus 20, 27, and 27% in nonfenestrated patients, respectively (P = 0.28, 0.21, and 0.32, respectively). In the second model, the nonfenestrated patients plus nondocumented patients had a shunt rate, conversion rate, and rate of clinical vasospasm of 16, 40, and 20%, respectively (P = 0.19, 0.33, and 0.60, respectively). In the matched cohort, fenestrated patients had a shunt rate, conversion rate, and rate of clinical vasospasm of 29, 67, and 20%, respectively, versus 20, 25, and 25% in nonfenestrated patients, respectively (P = 0.30, 0.24, and 0.20, respectively).
In contrast to other retrospective multisurgeon series, our retrospective single-surgeon series suggests that microsurgical fenestration of the lamina terminalis may not reduce the incidence of shunt-dependent hydrocephalus or cerebral vasospasm after aneurysmal subarachnoid hemorrhage. A prospective multicenter trial is needed to definitively address the use of this maneuver.
需要进行分流术的慢性脑积水和脑血管痉挛是动脉瘤性蛛网膜下腔出血后的常见并发症。最近的出版物研究了在动脉瘤手术期间对终板进行显微开窗术可能降低依赖分流的脑积水和脑血管痉挛发生率的可能性。我们回顾了一组由单一外科医生治疗的病例系列，以比较接受终板开窗术的患者与未接受该手术的患者的术后结果。
本研究是对2000年1月至2006年7月期间连续入住哥伦比亚大学医学中心的369例动脉瘤性蛛网膜下腔出血患者的病历进行的回顾性研究。所有患者均接受了开颅手术，并由一位神经外科医生（ESC）夹闭至少一个破裂的脑动脉瘤。比较接受终板开窗术的患者与未接受该手术的患者中依赖分流的脑积水、从入院时的急性脑积水转变为慢性脑积水以及临床脑血管痉挛的发生率。患者队列因此分为三个亚组：1）手术记录明确表明接受了终板开窗术的患者；2）手术记录明确表明未接受终板开窗术的患者；3）手术记录未表明是否接受终板开窗术的患者。我们进行了两项单独的分析，一是比较接受开窗术的患者与明确未接受开窗术的患者的术后结果，二是比较接受开窗术的患者与未接受开窗术以及记录未显示开窗术的患者的术后结果。为了进一步控制任何队列差异，我们在根据预测脑积水和血管痉挛的影像学和临床特征进行1:1匹配后，比较了接受开窗术的患者与未接受开窗术的患者。使用逻辑回归和多变量分析比较结果。
在第一个模型中，接受开窗术的患者的分流率、转化率和临床血管痉挛率分别为25%、50%和23%，而未接受开窗术的患者分别为20%、27%和27%（P分别为0.28、0.21和0.32）。在第二个模型中，未接受开窗术的患者加上记录未显示的患者的分流率、转化率和临床血管痉挛率分别为16%、40%和20%（P分别为0.19、0.33和0.60）。在匹配队列中，接受开窗术的患者的分流率、转化率和临床血管痉挛率分别为29%、67%和20%，而未接受开窗术的患者分别为20%、25%和25%（P分别为0.30、0.24和0.20）。
与其他回顾性多外科医生系列研究不同，我们的回顾性单外科医生系列研究表明，动脉瘤性蛛网膜下腔出血后对终板进行显微开窗术可能不会降低依赖分流的脑积水或脑血管痉挛的发生率。需要进行一项前瞻性多中心试验来明确解决该操作的应用问题。
